Healthcare Provider Details

I. General information

NPI: 1205905361
Provider Name (Legal Business Name): IMC-PEDIATRIC & ADOLESCENT MEDICINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 06/26/2020
Certification Date: 06/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4013 AIRPORT BLVD STE C
MOBILE AL
36608-2201
US

IV. Provider business mailing address

4013 AIRPORT BLVD STE C
MOBILE AL
36608-2201
US

V. Phone/Fax

Practice location:
  • Phone: 251-435-5437
  • Fax: 251-435-6744
Mailing address:
  • Phone: 251-435-5437
  • Fax: 251-435-6744

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number
License Number StateAL

VIII. Authorized Official

Name: ANTHONY PALAZZO
Title or Position: VICE PRESIDENT OF FINANCE
Credential:
Phone: 251-435-1361